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12090252 CITY OF CUPERTINO BUILDING PERMIT BUILDING.ADDRESS: 20252 NORTIICOVE SQ_ COXIVACfOR:NIATIIUR SANJAY K AND PERMIT NO: 12090252 RINA OWNER'S NANIE: MATIIUR SANIAY K AND RINA 20252 NORT'IICO%'li SQ DATE ISSUED:09272012 OWNER'S PIIONE: 3035889965 CUPEXI'INO,CA 95014 PDONE NO: ❑ LICENSED CONT'RACTOR'S DECLARATION BUILDING PEI2P11T INFO: BLDG 1_ ELECT r PLUMB r1 License Class Lic.N NISCH (- RESIDENTIAL[i COMMERCIAL (- Contractor Date hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:ADD NEW CAN LIGHTS TO KITCHEN (commencing with Section 7000)of Division 3 of the Business.@ Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and mill maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance,as provided for by Sy.FI Floor Area: Valuation:$240 Section 3700 of the Labor Code,for the performance of die work for which this permit is issued. AIIN Number:31641077.00 Occupancy Type: APPI:ICANT CER'I'IFIC.CI'ION I certify that I have read this application and state that the above information is correct.l agree to comply with all city and county ordinances and slate laws relating PERMIT EXPIRES �F WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupenino against liabilities,judgments, 180 DAYS FROM !,AST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply f,.,, with all non-point source regulations per the Cupenino Municipal Code,Section Issued b)•: ^ Date: 9.18. Signature Date RE ROOFS: OWNER-BUILDER DECLARATION All roofs shall be inspected prior to my roofing material being installed.If a roof is installed without first obtaining an inspection,1 agree to remove all new materials for hereby affirm that 1 am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with Wages as their sole compensation. Signature ofApplicant: Date: Will do the work,and the structure is not intended or offered for sale(Sec.7044, Business S Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGSTO RE CLASS"A"OR BETTER construct the project(Sec.7044,Business S Professions Code). 1 hereby affirm under penally of perjury,one of the following three HA%t RDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter-6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Ilealth S Safety Code,Sections 25505,25533,and 25534. I Will maintain Compensation,as provided forty Section 3700 of the labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ilcalth S performance of the work for which this permit is issued. Safety Code,Section 25532(x)should 1 store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should 1 use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air QualityManagement District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ilcallh S Safety Code,Sections 25505,25533,and 25534. 1 certify that in the performance of the work for which this permit is issued,I shall not employ my person in my mmnerso as to become subject to the Worker's Owner ora dl rizr I agent \ �� Compensation laws of California, If,after making this certificate ofexemption,I Date: become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked CONST RUCHON LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(See.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name correct..I agree to comply with all city and county ordinances and state laws relating to building construction.and hereby authorize representatives of this city to enter Lender's Address upon the above mentioned property for inspection purposes.(We)agree tosave indemnify and keep.harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCIII'1'IiCI"S DECLARATION granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. q ^�\- �iv1/ Licensed Professional Signature Date `\VVI HUIIIIII1SUdLIvu'r CC:— - IAUM11V 04L.UU Work Without Permit? O Yes e) No $0.00 `I Il dvanccd Planting Fees: 12, 09 GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 M ISC CUPERTINO (408)777-3228 • FAX(408)777-3333 • build InOQC1JDerilno.Ora []PLUMBING ❑MECHANICAL ELECTRICAL DIIUSCELLANEOUS PROFECFADDRFSS�1 ��,J1�'��\\ /+ r ' 11 t��..�A^� t� APN1 2Q()t � I f ( 07-7 OWNERNAME S�+O_QV1'j C�-1 l�tv I"• ' PHONE_ o,% S ✓e'/II IIY�7s EMAIL STREET ADDRESS Z I) S 2 SP crrr, sTArE. 7 ✓ FAx 'l�yL{J� ` ' /� /' 7 (�,,�s C 1 11)u CA - 9-'50'S I COMACT NAME S r I,��'1-i�M1' c o ,)N Y It ` PH �� V I/ E-MAIL STREETADDRESS CITY,STA ZIP b FAX ��e�-2IVD2-nI C0j% v �� cA �sosl 'tyO - ❑ owNEx-eLnnER ❑ MWERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ ra ANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC4 COMPM'Y NAME E-MAIL FAX STREETADDRESS CITY.STATE,ZIP PHONE ARCK=C;/FNGWEER NAME LICENSE NUMBER BUS.LIC p COMPANY NAMEE-MAIL FAX STREET ADDRESS CITY,STATE ZIP PHONE USE OF [I MASFD tar DUPLEX ULTI-FY PROJECT IN WILDLAND O YES PROJECT LY [3YES I ISTHEELDGAN El =S Y BUILDING: ❑COMMERCIAL URBANUMMU'ACEAREA NO FLOODZONE ❑NO EICHLER HOME? ❑ NO DESCRIPTION OF WORK TOTAL VALUATION: 2�V RECEIVED BY: I y By my signature below,I certify to each of the following: 1 am the property owner or authorized agent to act on the pmperry owner's behalf. I have readthis application and the in`onnation 1 have provid d cave zed the Description of Work and verify it is acnuxte. I agree to comply with all applicable local ordinances and sate laws relating to buildin o nnenOn. I autbOriZC representatives of CUDeninO to enter the above Q-identified ppmpe:.1 for inspection purposes. Signature of Applicant/Agent: �_ Daw: ! g7 �2,,( Z SUPPLEMENTAL INTORM?.TION REQUIRED OFFICE USE ONLY ❑ OVER-THE-COUNTER Y - ❑ EXPRESS v y ❑ STANDARD L z ❑ LARGE ❑ MAJOR AffiPMiscApp_1011.doc revised 06121111